Jared Strote

Whole-chest 64-MDCT of emergency department patients with nonspecific chest pain: Radiation dose and coronary artery image quality with prospective ECG triggering versus retrospective ECG gating.

OBJECTIVE The purpose of this study was to compare the patient radiation dose and coronary artery image quality of long-z-axis whole-chest 64-MDCT performed with retrospective ECG gating with those of CT performed with prospective ECG triggering in the evaluation of emergency department patients with nonspecific chest pain. SUBJECTS AND METHODS Consecutively registered emergency department patients with nonspecific low-to-moderate-risk chest pain underwent whole-chest CT with retrospective gating (n = 41) or prospective triggering (n = 31). Effective patient radiation doses were estimated and compared by use of unpaired Students t tests. Two reviewers independently scored the quality of images of the coronary arteries, and the scores were compared by use of ordinal logistic regression. RESULTS Age, heart rate, body mass index, and z-axis coverage were not statistically different between the two groups. For retrospective gating, the mean effective radiation dose was 31.8 +/- 5.1 mSv; for prospective triggering, the mean effective radiation dose was 9.2 +/- 2.2 mSv (prospective triggering 71% lower, p < 0.001). Two of 512 segments imaged with retrospective gating were nonevaluable (0.4%), and two of 394 segments imaged with prospective triggering were nonevaluable (0.5%). Prospectively triggered images were 2.2 (95% CI, 1.1-4.5) times as likely as retrospectively gated images to receive a high image quality score for each segment after adjustment for segment differences (p < 0.05). CONCLUSION For long-z-axis whole-chest 64-MDCT of emergency department patients with nonspecific chest pain, use of prospective ECG triggering may result in substantially lower patient radiation doses and better coronary artery image quality than is achieved with retrospective ECG gating.

Low-Risk Patients With Chest Pain in the Emergency Department: Negative 64-MDCT Coronary Angiography May Reduce Length of Stay and Hospital Charges

OBJECTIVE The current standard-of-care workup of low-risk patients with chest pain in an emergency department takes 12-36 hours and is expensive. We hypothesized that negative 64-MDCT coronary angiography early in the workup of such patients may enable a shorter length of stay and reduce charges. MATERIALS AND METHODS The standard-of-care evaluation consisted of serial cardiac enzyme tests, ECGs, and stress testing. After informed consent, we added cardiac CT early in the standard-of-care workup of 53 consecutive patients. Fifty patients had negative CT findings and were included in this series. The length of stay and charges were analyzed using actual patient data for all patients in the standard-of-care workup and for two earlier discharge scenarios based on negative cardiac CT results: First, CT plus serial enzyme tests and ECGs during an observation period followed by discharge if all were negative; and second, CT plus one set of enzyme tests and one ECG followed by discharge if all were negative. Comparisons were made using paired Students t tests. RESULTS For standard of care and the two CT-based earlier discharge analyses, the mean lengths of stay were 25.4, 14.3, and 5.0 hours; mean charges were

Diagnostic Performance of Resting CT Myocardial Perfusion in Patients With Possible Acute Coronary Syndrome

7,597,

Excessive use of force by police: a survey of academic emergency physicians.

6,153, and

Loperamide dependence and abuse

4,251. Length of stay and charges were both significantly less (p < 0.001) for the two CT-based analyses. CONCLUSION In low-risk patients with chest pain, discharge from the emergency department based on negative cardiac CT, enzyme tests, and ECG may significantly decrease both length of stay and hospital charges compared with the standard of care.

Use of force by law enforcement: an evaluation of safetyand injury.

OBJECTIVE Coronary CT angiography has high sensitivity, but modest specificity, to detect acute coronary syndrome. We studied whether adding resting CT myocardial perfusion imaging improved the detection of acute coronary syndrome. SUBJECTS AND METHODS Patients with low-to-intermediate cardiac risk presenting with possible acute coronary syndrome received both the standard of care evaluation and a research thoracic 64-MDCT examination. Patients with an obstructive (> 50%) stenosis or a nonevaluable coronary segment on CT were diagnosed with possible acute coronary syndrome. CT perfusion was determined by applying gray and color Hounsfield unit maps to resting CT angiography images. Adjudicated patient diagnoses were based on the standard of care and 3-month follow-up. Patient-level diagnostic performance for acute coronary syndrome was calculated for coronary CT, CT perfusion, and combined techniques. RESULTS A total of 105 patients were enrolled. Of the nine (9%) patients with acute coronary syndrome, all had obstructive CT stenoses but only three had abnormal CT perfusion. CT perfusion was normal in all other patients. To detect acute coronary syndrome, CT angiography had 100% sensitivity, 89% specificity, and a positive predictive value of 45%. For CT perfusion, specificity and positive predictive value were each 100%, and sensitivity was 33%. Combined cardiac CT and CT perfusion had similar specificity but a higher positive predictive value (100%) than did CT angiography. CONCLUSION Resting CT perfusion using CT angiographic images may have high specificity and may improve CT positive predictive value for acute coronary syndrome without added radiation and contrast. However, normal resting CT perfusion cannot exclude acute coronary syndrome.

Patient self assessment of pregnancy status in the emergency department

Objective: To determine the clinical experience, management and training of emergency physicians in the suspected use of excessive force by law enforcement officers. Methods: Surveys were mailed to a random sample of academic emergency physicians in the USA. Results: Of 393 emergency physicians surveyed, 315 (80.2%) responded. Of the respondents, 99.8% (95% CI 98.2% to 100.0%) believed excessive use of force actually occurs and 97.8% (95% CI 95.5% to 99.1%) replied that they had managed patients with suspected excessive use of force. These incidents were not reported by 71.2% (95% CI 65.6% to 76.4%) of respondents, 96.5% (95% CI 93.8% to 98.2%) had no departmental policies and 93.7% (95% CI 90.4% to 96.1%) had not received training in the management of these cases. Conclusions: Suspected excessive use of force is encountered by academic emergency physicians in the USA. There is only limited training or policies for the management of these cases.

Academic Emergency Physicians’ Experiences With Patient Death

Loperamide is a common over-the-counter antidiarrheal considered safe in a broad range of dosages and thought devoid of abuse potential. We describe the first case of a patient with loperamide dependence due to misuse of its opiate-like effects achieved by chronic massive oral ingestions. A 26-year-old man who was taking 800 mg of loperamide per day presented requesting detoxification referral. Loperamide has potential for euphoric effects and information on how to facilitate such effects is easily available. It is important for physicians to be aware of the potential for misuse of and dependence on loperamide, with symptoms mimicking opiate use.

Economic Outcome of Cardiac CT-Based Evaluation and Standard of Care for Suspected Acute Coronary Syndrome In the Emergency Department: A Decision Analytic Model

BACKGROUND Little is known about the frequency and types of injuries sustained from law enforcement use of force (UOF). The purpose of this study was to examine injury patterns and subject conditions after law enforcement UOF under real-life conditions. METHODS A retrospective cohort design was used to examine every UOF by a single police department from January through December, 2006. Data were collected from law enforcement UOF forms as well as medical records and included conditions surrounding the UOF, medical histories, and data from emergency department (ED) evaluations and hospital admissions. RESULTS Of 888 individuals subjected to force during the study period, 86.9% were men and the average body mass index was 25.8. Ages ranged from 10 to 77 years; juveniles comprised 5.6%. Of the types of force used by police, 73.7% were blows with arms or legs; 15.9% were Taser, 4.6% were capsicum spray, 1.7% were K-9, 0.7% were impact weapons, and 0.2% were firearms. Of the 630 (70.9%) with medical records, 78.7% had a substance abuse or psychiatric history. ED evaluations occurred for 187 (21.1% of) incidents. When laboratory workup occurred, 75.5% had positive urine toxicology and 45.9% had positive ethanol levels. Admission occurred in 15.5% (29) of ED presentations (3.3% of all subjects); of these, 9 (31.0%) were for UOF-related injury. Two subjects in the study died: one as a result of firearm injury and one by suicide after UOF; both were declared dead on scene. DISCUSSION Significant injuries related to law enforcement UOF in one city were rare and the only deaths were related to firearm use. A large percentage of those subjected to UOF had diagnoses of substance abuse and/or psychiatric conditions, and most hospital admissions were for problems unrelated to the UOF.

Emergency Physician Estimation of Blood Loss

Objectives: Pregnancy tests are often performed routinely for female emergency department (ED) patients of reproductive age. One major reason is a perception that patients are unreliable in predicting their own pregnancy status. We hypothesised that patients could reliably predict that they were not pregnant. Methods: The study used a prospective cohort design, in an urban academic ED, from January 19 to May 19, 2004. All patients for whom a pregnancy test was ordered were asked about their sexual history as well as two additional questions: “Do you think you might be pregnant?” and “Is there any chance you could be pregnant?” Patients with already documented pregnancies were excluded. Results: A total of 474 patients had pregnancy tests performed that met inclusion criteria. Eleven (2.3%) tests were positive. Among patients who answered no to both questions (337), one test (0.3%) was positive (negative predictive value (NPV) 99.7%, likelihood ratio (LR) 0.13 (95% CI, 0.02 to 0.82)). The other historical factor with a high NPV (100%) was not being sexually active (LR not calculable). All pregnancies occurred in patients with gastrointestinal or genitourinary as the chief complaint: this comprised only 56% of the presentations for which tests were ordered. Conclusion: Sexual history and self assessment can be used as a highly effective predictor of a patient not being pregnant. Given the risks of missed pregnancy in the ED, and low monetary and time cost of pregnancy tests, frequent testing is still recommended in most instances.